An N of 1: Why I Left Corporate Medicine for Midlife Care

When I finished residency in 2017, I started practice as an attending physician under real financial pressure. I had $300,000 in student loan debt, three kids with college on the horizon — including a daughter heading into her freshman year of high school — and I was 43 years old.

Before medicine, I'd spent exactly one year in corporate employment: at 25, as an ad sales assistant for the Boulder Daily Camera. So there was no retirement plan and no college savings. I did what any sensible newly minted physician would do — I took the best-paying job I could find.

Family medicine sits at the bottom tier of physician compensation, trailing the surgical and subspecialties by a wide margin. But it still pays quite a bit more than being a piano player — the thing I'd quit that ad sales job to do in the first place. I told myself, this is the last job I'll ever have. We settled into a comfortable rhythm built on my corporate income, and for a while it felt like we could do it forever.

Then I noticed something. I wasn't playing music anymore.

The Slow Erosion

I'd come home exhausted, peel myself out of my scrubs, and lament my lack of energy. Sore, tired, stressed. From the second I hit the door at work until the moment I left, an endless stream of emails, phone calls, and patient encounters competed with requests from nurses, from pharmacists, and from the electronic medical record itself.

My patient panel swelled to as many as 3,500 people who called me their primary care doctor — when in reality I didn't know most of their names unless I pulled up their chart first. The idea that I was a community physician serving my hometown was one my corporate job never quite lived up to, even though I could bike to work in ten minutes. Of course I knew some of them. The ones I clicked with were the ones I stayed for.

What I Was Never Taught

As I entered my 50s, I noticed how much about caring for people in midlife I had never been taught.

My training focused on chronic disease — and rightly so. In residency you care for people in the hospital and clinic, and they follow up after discharge for exacerbations of their heart, lung, or diabetic conditions. It's essential to understand how chronic illness affects the sickest among us.

But early on, I noticed a detachment from the things we couldn't explain — anything labeled a "syndrome." I always found that word attached to a collection of symptoms for which we could discern no reliable cause or treatment. Irritable bowel syndrome. Chronic fatigue syndrome. Chronic pain syndrome. Hypermobility Syndrome. Primary care physicians at every stage learn a kind of quiet cynicism toward these patients: we have a handful of options that work for some people but not all — and in fee-for-service medicine, with 20 patients a day, we get about five minutes to discuss one or two of them before moving on.

When Empathy Runs Out

Patients arrive frustrated, and it's often worst when you're new to them. If you're a new doctor to someone, chances are they just lost or left their old one. If they loved that doctor, meeting you is something they dread — how could you possibly measure up? If they hated that doctor, they've already been burned by the system, and now they're sizing up this new young physician wondering how you'll be any different.

Meanwhile, you're just getting your bearings in a system where overworking you is the norm. You survive encounter after encounter putting empathy out into the room — but empathy curdles into sympathy when you're exhausted. Instead of understanding how a patient feels, you start to feel the way they feel. And when you feel sick, tired, and unheard yourself, you do a terrible job of aligning with your most difficult patients.

The Thyroid Discourse

This is exactly what fed a discussion I watched on the Family Medicine subreddit this week, where doctor after doctor belittled patients for requesting a thyroid workup beyond a TSH.

"It doesn't change management," they said. "It's a disaster," chimed in an endocrinologist. "Jesus take the wheel." One comment — "you can safely assume that anyone suggesting a reverse T3 is a quack" — got 134 upvotes.

I offered my own view: that ordering $60 worth of labs can spare a patient the wait and the specialist copay. That collaborating with patients means actually talking with them and showing them what you know about how the thyroid works. That adjusting medication to include bioidentical T3 (nearly all hypothyroidism in this country is treated with T4 alone — which works for most, but not for all), suggesting a few Brazil nuts (selenium supports thyroid function, though too much is toxic), or recommending someone watch the sunrise (circadian regulation is one of the few reliable ways to modulate the cortisol that feeds thyroid dysfunction) all fall squarely within family medicine.

A lack of clear direction, thin evidence, even discouragement from popular references like UpToDate — none of that should preclude a physician's willingness to learn something new. In response, someone suggested that while many minds today may be "too closed," mine might be "too open."

I'll take it.

Why Midlife Gets Dismissed

This is the pattern in midlife care. Weight gain and fatigue get waved off as "just getting older." Requests to check hormone levels get flatly denied. Insurance companies don't want to cover the tests, so the lack of consensus becomes the justification for not checking. Drug companies won't profit from more estradiol or testosterone prescriptions, so the studies that might build that evidence remain few and far between.

Medical knowledge is expanding at a staggering pace — by one widely-cited estimate, its doubling time fell from about 50 years in 1950 to a projected 73 days by 2020. But what people in midlife are learning and focusing on is rapidly diverging from where corporate medicine is heading. "Lack of evidence" dominates the criticism of peptides, which have been around for years and are increasingly everywhere in the healthfluencer world.

This shouldn't be politicized. And the conversation shouldn't be dominated by untrained voices. Primary care doctors should be taking point on midlife — because every one of our patients is going to go through it.

So I Left

I picked up the ball of Direct Primary Care that was first thrown to me in 2017, when I learned about it and threw it back as fast as I could — because I had college to pay for and couldn't imagine taking on the risk of a new business with a kid about to enroll.

It's still a risk. But I know this is where I'm supposed to be. Figuring out a better approach to my own midlife wasn't something I was willing to postpone for another 20 years while waiting for more evidence. I am an n of 1 — and my patients get to be that too.

If you've felt dismissed by modern medicine while trying to explain something that doesn't fit neatly in a box — if you're being driven toward ordering your labs from a Facebook ad, spending hundreds of dollars for an alternative non-physician healer, or signing up with a weight-loss club or a hormone mill for something your doctor can’t or won’t consider prescribing— let me offer one suggestion. Don't give up on Western medicine just yet. Find a direct primary care doctor willing to help you ask and answer personalized questions, without worrying about what your insurance will cover, and without trying to force your square peg into the round hole that fee-for-service medicine confines itself to.

That's the doctor I set out to be.

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